82 Rev. odonto cinc.

2008;23(1):82-86
Calcium hydroxide and endodontic infection
R RR RReviso de Literatura eviso de Literatura eviso de Literatura eviso de Literatura eviso de Literatura
Efficacy of calcium hydroxide dressing in endodontic Efficacy of calcium hydroxide dressing in endodontic Efficacy of calcium hydroxide dressing in endodontic Efficacy of calcium hydroxide dressing in endodontic Efficacy of calcium hydroxide dressing in endodontic
infection treatment: a systematic review infection treatment: a systematic review infection treatment: a systematic review infection treatment: a systematic review infection treatment: a systematic review
Eficcia da pasta de hidrxido de clcio no tratamento de infeco Eficcia da pasta de hidrxido de clcio no tratamento de infeco Eficcia da pasta de hidrxido de clcio no tratamento de infeco Eficcia da pasta de hidrxido de clcio no tratamento de infeco Eficcia da pasta de hidrxido de clcio no tratamento de infeco
endodntica: uma reviso sistemtica endodntica: uma reviso sistemtica endodntica: uma reviso sistemtica endodntica: uma reviso sistemtica endodntica: uma reviso sistemtica
Carlos Estrela
a
Daniel de Almeida Decurcio
a
Ana Helena Gonalves de Alencar
a
Gilson Blitzkow Sydney
b
Julio Almeida Silva
a
a
Department of Endodontics, Federal University
of Gois, Goinia, GO, Brazil
b
Department of Endodontics, Federal University
of Paran, Curitiba, PR, Brazil
Correspondence: Correspondence: Correspondence: Correspondence: Correspondence:
Carlos Estrela
Centro de Ensino e Pesquisa Odontolgica do
Brasil (CEPOBRAS)
Av. C-198, Quadra 487, Lote 9, Jardim Amrica
Goinia, GO Brazil
74270-040
E-mail: estrela3@terra.com.br
Recebido: 20 de novembro, 2007
Aceito: 07 de janeiro, 2008
Abstract
Pupose: To perform a systematic review of the efficacy of calcium hydroxide (CH) dressing
prepared with different vehicles on the treatment of teeth with endodontic infection.
Methods: Search strategies included electronic search in databases (MEDLINE, EMBASE,
CENTRAL) from 1966 to January 2007 and manual search in endodontic journals and
references of previously selected studies. The following terms were used: calcium hydroxide,
chlorhexidine, root canal infection, faecalis, intracanal dressing, endodontic infection,
intracanal medicament, paramonochlorophenol, para monochlorophenol, and
p-monochlorophenol.
Results: From the 71 in vivo studies retrieved, five clinical studies met the inclusion criteria.
Saline solution was the vehicle of CH dressing in all five included studies, and only one
study compared saline versus chlorhexidine as vehicles of CH dressing. From a total of 130
teeth with endodontic infection, 39 teeth (30%) had remaining microorganisms after
sanitation and CH dressing with saline.
Conclusion: Adequate sanitation and CH dressing with saline vehicle reduce microorganisms
in teeth with endodontic infection.
K KK KKey words: ey words: ey words: ey words: ey words: Calcium hydroxide; intracanal dressing; endodontic infection; apical
periodontitis; systematic review
Resumo
Objetivo: Realizar uma reviso sistemtica sobre a eficcia de pastas de hidrxido de
clcio preparadas com diferentes veculos no tratamento de dentes com infeces
endodnticas.
Metodologia: As estratgias de busca incluram buscas eletrnicas em bases de dados
(MEDLINE, EMBASE, CENTRAL) de 1966 a janeiro de 2007 e busca manual em peridicos
especializados e referncias de estudos selecionados. Os seguintes unitermos foram
utilizados: calcium hydroxide (CH), chlorhexidine, root canal infection, faecalis, intracanal
dressing, endodontic infection, intracanal medicament, paramonochlorophenol, para
monochlorophenol e p-monochlorophenol.
Resultados: Dos 71 trabalhos in vivo obtidos, cinco estudos clnicos satisfizeram os critrios
de incluso. Soluo salina foi o veculo na pasta de hidrxido de clcio em todos os
cinco estudos includos na reviso, e apenas um estudo comparou soluo salina versus
clorexidina como veculo da pasta de hidrxido de clcio. De um total de 130 dentes com
infeco endodntica, 39 dentes (30%) apresentaram microrganismos aps o procedimento
de sanificao combinado com pasta de hidrxido de clcio associada soluo fisiolgica.
Concluso: O adequado procedimento de sanificao do canala associado pasta de
hidrxido de clcio com veculo de soluo fisiolgica reduzem a quantidade de
microrganismos em dentes com infeco endodntica.
P PP PPalavras alavras alavras alavras alavras- -- --chave: chave: chave: chave: chave: Hidrxido de clcio; medicao intracanal; infeco endodntica;
periodontite apical; reviso sistemtica
Rev. odonto cinc. 2008;23(1):82-86 83
Estrela et al.
Introduction
Intracanal dressing was regarded as a fundamental step
of endodontic treatment for many years. At present, the
real effect of intracanal dressing on teeth with apical
periodontitis is controversial. The chemical-mechanical
preparation of root canals has been considered the clinical
procedure mainly responsible for microbial control due to
intracanal sanitation, including canal emptying, enlarge-
ment, and irrigation.
Among the intracanal dressings commonly used, calcium
hydroxide (CH) paste has been shown to be biocompatible
and effective in teeth with apical periodontitis (1). CH paste
can be prepared with different vehicles, such as distilled
water, saline, camphorated paramonochlorophenol, chlorhe-
xidine, polyethylenoglicol, propilenoglicol, Otosporin, or
glicerine (2-5), but it still is unclear if there is a synergistic
antimicrobial effect between vehicle and CH. The anti-
microbial mechanism of CH has been associated with ion
availability, diffusion, and velocity of dissociation, as the
dissociated ions calcium and hydroxide participate in
enzymatic reactions in bacteria and tissues (6,7). The
hydroxide ion can affect the viability of anaerobic bacteria
present in apical periodontitis, such as E. faecalis, which is
very resistant to canal disinfection (8-10). For example, CH
dressing seems to be more effective than camphorated
paramonochlorophenol or camphorated phenol in the
treatment of infected root canals with apical lesions (2).
However, lack of standardization of procedures and limited
sample size often compromise the direct comparison of
previous clinical reports.
Good scientific evidences are mandatory to elaborate
clinical decisions, yet few systematic reviews or meta-
analysis have been developed in Endodontics (12,13).
Therefore, this study aimed to systematically review
published prospective clinical research to investigate the
efficacy of CH dressing in the treatment of teeth with
endodontic infection. The specific aim was to assess the
influence of the vehicle used for CH dressing preparation
on reduction of microbial contamination in teeth with apical
periodontitis in humans.
Methods
Prospective clinical studies were searched using electronic
and manual search strategies. The following databases were
searched on January 2, 2007: MEDLINE (with no filter,
from 1966 to January 2, 2007), EMBASE (with no filter,
from 1980 to January 2, 2007), Cochrane Oral Health Group
Trials Register and Cochrane Central Register of Controlled
Trials (CENTRAL). The mesh terms used were: 1. Calcium
hydroxide and chlorhexidine OR, 2. Calcium hydroxide and
root canal infection OR, 3. Calcium hydroxide and faecalis
OR, 4. Calcium hydroxide and intracanal dressing OR,
5. Calcium hydroxide and endodontic infection OR,
6. Calcium hydroxide and intracanal medicament OR,
7. Calcium hydroxide and paramonochlorophenol OR,
8. Calcium hydroxide and para monochlorophenol OR,
9. Calcium hydroxide and p-monochlorophenol. The manual
search was conducted by checking Endodontics journals and
the references of previously selected studies for other
potentially relevant clinical trials.
Studies were selected by analysis of their titles and abstracts
according to predefined eligibility criteria (Table 1) by two
independent reviewers. Full-text copies were obtained of
all selected studies and those where the title and abstract
were not sufficient to decide for or against the study
inclusion. Table 2 displays the clinical studies in humans
retrieved by the search strategies and excluded from the final
analysis according to the inclusion/exclusion criteria.
Two reviewers independently assessed the methodological
quality of the selected studies. For each study, the following
data were collected for qualitative analysis: sample size, type
of infection (primary or secondary), type of tooth and root
canal, microbiological technique, microbial assessment in base-
line samples, vehicle of CH dressing, substances used for
canal sanitation, duration of the intracanal dressing previously
to canal filling, and microbial assessment in final samples.
T TT TTable 1. able 1. able 1. able 1. able 1. Criteria for inclusion and
exclusion of studies
a. Inclusion criteria
1. Related to the efficacy of CH dressing on the treatment of endodontic infection
2. Nonsurgical root canal treatment
3. Subjects with medical history that would not compromise the outcomes
4. Microbiological samples collected before and after sanitation
5. Treatment outcome stated as positive or negative microbial culture
b. Exclusion criteria
1. In vitro studies
2. Animal models
3. Literature reviews
4. Case reports
5. Absence of abstract
6. Non-English language
7. Studies on the efficacy of intracanal dressings other than CH
8. Studies in deciduous teeth
9. Studies where the vehicle associated with CH was not specified
10. No collection of microbiological samples before or after sanitation
84 Rev. odonto cinc. 2008;23(1):82-86
Calcium hydroxide and endodontic infection
Results
The search strategies yielded 303 published
papers: 22 literature reviews, 71 in vivo
studies (clinical studies in humans or animal
models), 34 cases reports, and 178 in vitro
studies (25 studies with agar diffusion test,
31 with direct contact test, 11 with cell
culture, 75 with contaminated dentine
specimens, 20 with microbial colonization
cfu, and 16 with others methodologies)
(Figure 1). Regarding clinical studies in
humans, most retrieved studies did not meet
the inclusion criteria for data analysis and
were excluded (Table 2). Five in vivo studies
in humans were considered for analysis of
the outcome variables (Table 3).
Qualitative analysis of the five included
studies was performed for a total of 130
teeth with primary or secondary infection
and baseline microbial assessment. After
intracanal sanitation (root canal preparation,
use of irrigant solutions saline, sodium
hypochlorite 0.5 to 5.25%) and CH dressing
for 7 to 28 days, 39 teeth (30%) showed
remaining microorganisms. Saline solution
was the vehicle of CH dressing in all five
included studies, and one study compared
saline versus saline plus chlorhexidine as
vehicles of CH dressing.
T TT TTable 2. able 2. able 2. able 2. able 2. Studies in humans excluded from the present systematic review
Excluded studies Excluded studies Excluded studies Excluded studies
Reason for Reason for Reason for Reason for
exclusion exclusion exclusion exclusion
Excluded studies Excluded studies Excluded studies Excluded studies
Reason for Reason for Reason for Reason for
exclusion exclusion exclusion exclusion
1. Ghoddusi et al., 2006 10 19. Siqueira Jr et al., 2002 10
2. Al-Omari et al., 2006 7 20. Peciuliene et al., 2001 9
3. Oncaag et al., 2006 8 21. Shuping et al., 2000 9
4. Silva et al., 2006 10 22. Walia et al., 2000 10
5. Gesi et al., 2006 10 23. Waterhouse et al., 2000 8
6. Waltimo et al., 2005 9 24. Weiger et al., 2000 10
7. Caliskan, 2005 9 25. Reit et al., 1999 7
8. Rocha & Cardoso, 2004 8 26. Molander et al., 1999 9
9. Nakajo et al., 2004 10 27. Trope et al., 1999 10
10. Yoldas et al., 2004 10 28. Fava, 1998 10
11. Pacios et al., 2004 10 29. Barbosa et al., 1997 10
12. Caliskan, 2004 10 30. Caliskan & Sen., 1996 10
13. Molander & Dahlen, 2003 10 31. Fava, 1992 10
14. Ehrmann et al., 2003 10 32. Sjgren et al., 1991 9
15. Zamany et al., 2003 10 33. Molander et al., 1990 7
16. Chvez de Paz et al., 2003 10 34. Lundin et al., 1990 7
17. Rodd et al., 2002 7 35. Eronat & Eronat, 1989 6
18. Cheung, 2002 10 36. Klinger et al., 1975 6

Legenda: ADT Agar Diffusion Test cfu Colony formation unity
DCT Direct Contact Test CD Contaminated Dentine
CCT Cell Culture Test
F FF FFig ig ig ig ig.1. .1. .1. .1. .1. Distribution of the studies retrieved for the present systematic review.
Systematic Review
303 studies (100%)
Included studies
5 studies (1.6%)
Excluded studies
298 studies
Reviews
22 studies
In Vivo studies
71 studies
Humans
41 studies
Clinical
24 studies
Microbiological
21 studies
CD
75 studies
CCT
11 studies
DCT
31 studies
ADT
25 studies
cfu
20 studies
Healing
26 studies
Animal
30 studies
In Vitro studies
178 studies
Case Reports
34 studies
Others
16 studies
Rev. odonto cinc. 2008;23(1):82-86 85
Estrela et al.
Discussion
Previous studies questioned the mandatory indication of
intracanal dressing in the clinical treatment of infected root
canals (2,14-18). Also, most experiments in the literature
were developed in vitro or in animal models, and care
should be taken to extrapolate those results to the clinics.
Systematic reviews use a strict methodological approach to
search, select, evaluate, and analyze original data from
primary sources. Established criteria for inclusion and
exclusion of papers, hierarchy of the selected studies (level
A: randomized controlled trials/meta-analysis, level B: non-
randomized clinical study, and level C: consensus/personal
opinion) (19), and combined data analysis allow a more
scientific evaluation of the literature to provide evidence-
based clinical directions. However, an assessment of the
quality of published systematic reviews related to dental
interventions revealed that only 19% studies properly
identified relevant papers (20).
In the present study, from the 71 in vivo studies retrieved
using the search strategies, only five (21-25) met the
inclusion criteria and were analyzed. Comparison of results
was compromised to some extent due to the lack of
experimental standardization in relation to the limits of
canal instrumentation, technique of root canal preparation,
type and size of teeth, materials and endodontic technique,
criteria to identify periapical lesion, etc. The limited sample
size and heterogeneity of studies in relation to clinical
protocols precluded this review from a meta-analysis.
However, the results of the present review corroborate
previous studies on the antibacterial effect of intracanal
dressing (12,13).
Initially the objective of this study was to review clinical
studies on CH dressings prepared with different vehicles as
in vitro results showed that the vehicle may influence the
chemical characteristics and antimicrobial potential of CH
dressing (3,4). However, only one out of five papers selected
in the present systematic review addressed this issue, and
20% of the teeth treated with CH dressing with chlorhe-
xidine still were contaminated after 14 to 21 days (25).
Different substances have been proposed as adjuvant
components of CH dressing or sole intracanal medication,
T TT TTable 3. able 3. able 3. able 3. able 3. Studies included in the present systematic review on the efficacy of CH dressing in the treatment of teeth with endodontic infection
Reference Reference Reference Reference n nn n TI TI TI TI Tooth Tooth Tooth Tooth Technique Technique Technique Technique Vehicle Vehicle Vehicle Vehicle IS IS IS IS Intervention Intervention Intervention Intervention Med Med Med Med Outcome Outcome Outcome Outcome
Chu et al. (21) 35 1
18 uni
14 bi
3 tri
Culture Saline 35 0.5% SH + CH 7 d 11
rstavik et al. (22) 23 1 23 uni Culture Saline 22 Saline + CH 7 d 8
Peters et al. (23) 21 1 DNI Culture Saline 21 2% SH + CH 28 d 2
Souza et al. (24) 12 1 12 uni
Checkerboard
DNA
Saline 12
5.25% SH +
CH
14 d 6
Zerella et al. (25)
Group 1: 20
Group 2: 20
2 40 uni
Culture
PCR
G1: Saline
G2: 2%
CHX
G1: 20
G2: 20
1% SH + CH
14 to 21
d
G1: 8
G2: 4
n sample size; TI Type of infection (1 primary, 2 secondary); Tooth uniradicular / biradicular / triradicular; DNI data not identified; Technique Identification
procedure; Vehicle (CHX chlorhexidine); IS Initial microbiological sample; Intervention (SH sodium hypochlorite, CH calcium hydroxide dressing); Med duration
of intracanal dressing; Outcome number of teeth with remaining microorganisms.
but their antimicrobial efficacy and safety is controversial.
For example, phenol compounds should not be used as
intracanal medication due to high-toxicity and limited
clinical effectiveness (26). Haenni et al. (27) evaluated the
antimicrobial and chemical effects of CH dressing with
saline plus chlorhexidine, sodium hypochlorite, or iodine
potassium, and reported no improvement of antimicrobial
effect with addition of any substance. Likewise, the use of
chlorhexidine as irrigant solution before CH dressing was
as effective as 2.5% sodium hypochlorite irrigation plus CH
dressing in the treatment of apical periodontitis in dogs (15).
When chlorhexidine is associated with CH, the pH is
approximately 10 and the surface tension increases to
55dinas/cm, which does not improve the properties of CH
with saline (28). Also, chlorhexidine does not promote
degradation of the microbial lypopolysaccharides as CH
with saline does (11). On the other hand, chlorhexidine was
reported to increase the antimicrobial potential of CH,
compared to other vehicles such as saline, camphorated
paramonochlorophenol, and propylenoglycol (29). Further
investigation is necessary to clarify whether addition
of chlorhexidine or other substance to CH dressing
significantly impacts clinical treatment.
Successful endodontic treatment of teeth with apical
periodontitis also may be related to other variables not
assessed in this review. For example, Kvist et al. (30) found
that microbial content significantly decreases after root
canal preparation, and reported intracanal recontamination
in 29% of teeth treated in one clinical session in comparison
with 36% of teeth treated in two sessions. Therefore,
prospective controlled clinical trials on the efficacy of
endodontic treatment of teeth with apical periodontitis
should balance the combined effect of materials, technique,
and procedures to provide good scientific information to
develop clinical guidelines.
Conclusions
Within the limitations of this study, the results suggest that
adequate sanitation procedure and CH paste with saline
vehicle reduce microbial contamination in teeth with apical
periodontitis.
86 Rev. odonto cinc. 2008;23(1):82-86
Calcium hydroxide and endodontic infection
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